Nokea
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
- A. It is less painful for the client.
- B. Palpation and percussion can increase peristalsis.
- C. It identifies any potential areas of abdominal tenderness.
- D. It gives the client more time to become comfortable with the examiner.
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
You may also like to solve these questions
A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?
- A. Ptosis
- B. Nystagmus
- C. Scleral icterus
- D. Exophthalmos
Correct Answer: B
Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.
Which of the following is an example of an extended care facility?
- A. Home health agency
- B. Suicide prevention center
- C. State-owned psychiatric hospital
- D. Nursing facility
Correct Answer: D
Rationale: An extended care facility typically provides long-term care for individuals who require continuous assistance with activities of daily living. A nursing facility fits this description as it offers skilled nursing care and assistance with daily activities. Choices A, B, and C are incorrect because a home health agency provides care in the patient's home, a suicide prevention center focuses on mental health crisis intervention, and a state-owned psychiatric hospital offers mental health treatment, none of which are synonymous with extended care facilities.
A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?
- A. Constriction of the underlying blood vessels
- B. An increased amount of bilirubin in the blood
- C. Increased perfusion of the surrounding tissues
- D. Excess blood in the dilated superficial capillaries
Correct Answer: D
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.
A nurse assisting with data collection regarding the client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?
- A. Myopia
- B. Hyperopia
- C. Photophobia
- D. Accommodation
Correct Answer: D
Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light. Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?
- A. Emergency
- B. Follow-up
- C. Complete (total)
- D. Problem-centered
Correct Answer: B
Rationale: The correct answer is 'Follow-up.' A follow-up database is used to assess the status of an identified problem at regular intervals. An emergency database is for urgent data collection during life-saving measures. A complete database involves a full health history and physical examination. A problem-centered (episodic) database focuses on a limited or short-term issue, typically centered around one problem or body system.